Minimally Invasive Aortic Surgery via Upper Hemi-sternotomy is Comparable to Those with Full Sternotomy: A Single Center Experience with over 400 Patients

Objective: Minimally access is seldom used for thoracic aortic surgery. The purpose of this study was to assess the results in 402 thoracic aortic patients operated between 4/2011 and 3/2016 either via upper hemi-sternotomy or full sternotomy.

Methods: Group A (hemisternotomy): 210 patients (male 137, age 60 ± 14 years) were operated via upper hemi-sternotomy. 41 patients underwent isolated ascending aortic replacement and 64 patients aortic valve replacement with supra-commissural ascending aortic replacement, respectively. Fifty-five patients underwent Bentall and 46 patients underwent valve sparing David procedure. Group B (full sternotomy): 192 patients (male 114, age 63 ± 13 years) were operated via full sternotomy. 48 patients underwent isolated ascending aortic replacement and 65 patients aortic valve replacement with supra-commissural ascending aortic replacement, respectively. 52 patients underwent Bentall and 27 patients David procedure, respectively.

Results: Group A: There were two intra-operative conversions to full sternotomy (one in Bentall-group and one in AVR with supracommissural aortic replacement group). The stroke was 3.8% (n = 8). Re-thoracotomy for bleeding was necessary in 4.8% (n = 10). One patient with acute renal failure required temporary dialysis (Bentall group). The post-operative ventilation time was 0.6 ± 0.6 days. One patient died within the 30 days (Bentall). In the post-operative echocardiography in the David subgroup only 2.2% (1/46) had aortic valve insufficiency grade >1, while the rest had either no or trivial insufficiency, respectively. Group B: The stroke was 4.1% (n = 8). Re-thoracotomy for bleeding was necessary in 7.3% (n = 14). Two patients with acute renal failure required temporary dialysis (ascending aortic replacement). The post-operative ventilation time was 0.6 ± 0.6 days. One patient died within the 30 days (Bentall group). In the post-operative echocardiography in the David subgroup no patient had aortic valve insufficiency grade >1.

Conclusions: Minimally access thoracic aortic replacement can be performed safely. The key to success is a step by step technique of moving from technically simpler isolated ascending aortic replacements to more demanding aortic root replacements. Meticulous hemostasis and attention to surgical details are of utmost importance to prevent peri-operative complications.